The nurse is reviewing the patient's medical records which include history and physical, nurses' notes, imaging studies, and orders.

Exhibits

The nurse is asked to mark whether the assessment findings indicate that the treatment was effective or ineffective.

Which of the following options best describes the effectiveness of the treatment?

The treatment was effective.

The treatment was ineffective.

The treatment was partially effective.

It is too early to determine the effectiveness of the treatment.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Diminished breath sounds in the right lung: This finding suggests that there is still some inflammation or fluid in the right lung, which is not consistent with fully effective treatment. Normal breath sounds should be clear and equal bilaterally.

PaCO2 55 mm Hg on a blood gas: This finding is slightly elevated, indicating that the patient may be having some difficulty clearing carbon dioxide from the lungs. A normal PaCO2 is 35-45 mm Hg.

Rhonchi in the right lung: Rhonchi are a type of abnormal breath sound that is caused by secretions in the airways. This finding suggests that there is still some inflammation or infection in the right lung.

Choice B rationale:

Oxygen saturation greater than 94%: This finding is within the normal range and indicates that the patient is getting enough oxygen.

Client ambulates without shortness of breath: This finding is a positive sign that the patient's respiratory status is improving. Symmetric chest expansion: This finding indicates that both lungs are expanding equally, which is a good sign.

Choice C rationale:

The assessment findings are mixed, with some findings suggesting improvement (oxygen saturation, ambulation without shortness of breath, symmetric chest expansion) and some findings suggesting that the infection is not fully resolved (diminished breath sounds, elevated PaCO2, rhonchi). This suggests that the treatment has been partially effective, but that the patient may need further treatment to fully resolve the pneumonia.

Choice D rationale:

It is important to evaluate the effectiveness of treatment over time, but the assessment findings in this case are clear enough to determine that the treatment has been partially effective.

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Correct Answer is C

Explanation

Choice A rationale:

Checking the patient's temperature again is not a priority at this time. The patient's temperature is within the normal range, and there is no indication that it is the cause of the patient's hypoxia.

Focusing on temperature measurement could delay more crucial interventions to address the patient's breathing difficulty.

Choice B rationale:

While monitoring the patient's heart rate is important, it is not the most immediate priority in this situation. The patient's heart rate is elevated, but it is not dangerously high.

The elevated heart rate is likely a compensatory response to the patient's low oxygen saturation. Addressing the underlying cause of the hypoxia, which is likely respiratory in nature, will also help to stabilize the heart rate.

Choice C rationale:

Observing the patient's breathing is the most important action the nurse can take at this time. The patient's respirations are rapid and shallow, indicating respiratory distress.

This is a serious condition that requires immediate intervention. By observing the patient's breathing, the nurse can assess the severity of the distress and determine the best course of action.

The nurse can observe for signs of increased work of breathing, such as use of accessory muscles, nasal flaring, and retractions. They can also auscultate the lungs to assess for any abnormal breath sounds, such as wheezing or crackles.

This information will help the nurse to determine the underlying cause of the respiratory distress and to initiate appropriate interventions, such as administering oxygen, positioning the patient, or calling for assistance from a respiratory therapist.

Choice D rationale:

Checking the patient's blood pressure is not a priority at this time. The patient's blood pressure is within the normal range. While it is important to monitor the patient's blood pressure, it is not the most immediate concern in this situation.

A. Carbon dioxide is converted in the kidneys for elimination. B. Hyperventilation is eliminating carbon dioxide rapidly. C. High levels of carbon dioxide have accumulated in the blood. D. Blood oxygen levels are stimulating the respiratory rate.

Correct Answer is C

Explanation

Choice A rationale:

Incorrect. The kidneys do play a role in acid-base balance, but they primarily eliminate acids other than carbon dioxide. They do not significantly convert carbon dioxide for elimination.

Elaboration: While the kidneys help regulate acid-base balance through reabsorption and excretion of bicarbonate and hydrogen ions, their role in carbon dioxide elimination is minimal. They primarily excrete acids like uric acid, phosphoric acid, and lactic acid.

Choice B rationale:

Incorrect. Hyperventilation would decrease carbon dioxide levels, not contribute to respiratory acidosis. Respiratory acidosis is characterized by elevated carbon dioxide levels.

Elaboration: Hyperventilation leads to rapid and excessive breathing, causing a decrease in carbon dioxide levels in the blood. This can result in respiratory alkalosis, not respiratory acidosis.

Choice C rationale:

Correct. Respiratory acidosis is caused by the accumulation of carbon dioxide in the blood. This can happen due to impaired ventilation, such as in conditions like chronic obstructive pulmonary disease (COPD), pneumonia, or respiratory failure.

Elaboration: Carbon dioxide is produced as a byproduct of cellular metabolism. It is normally removed from the body through exhalation. When ventilation is impaired, carbon dioxide cannot be efficiently eliminated, leading to its buildup in the blood. This excess carbon dioxide reacts with water to form carbonic acid, lowering blood pH and causing respiratory acidosis.

Choice D rationale:

Incorrect. Low blood oxygen levels (hypoxemia) can stimulate the respiratory rate, but this would not directly cause respiratory acidosis. It might lead to hyperventilation, which could potentially cause respiratory alkalosis.

Elaboration: The body's respiratory center in the brainstem regulates breathing based on blood oxygen and carbon dioxide levels. Hypoxemia triggers a compensatory increase in respiratory rate to enhance oxygen intake. However, this response does not directly contribute to respiratory acidosis.

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Naxlex Comprehensive Predictor Exams

The patient’s vital signs are as follows: Temperature 97.5 F (36.4 C), Heart rate 104 beats/minute, Respirations 29 breaths/minute, Blood pressure 119/82 mm Hg, Oxygen saturation 89%. Oxygen mask applied.What should the nurse do next?

Correct Answer is C

Explanation

A client who is experiencing respiratory distress is admitted with respiratory acidosis.Which pathophysiological process supports the client's respiratory acidosis?

Correct Answer is C

Explanation

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell.The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?

The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results.Which diagnostic test should the nurse review to confirm the diagnosis of TB?

A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed.Which prescription should the nurse teach the client to use for the skin condition?

Patient Data shows that on Day 1, there were no active processes.On Day 2, there were small bilateral lower lobes pulmonary infiltrates with the right lower lobe showing increased involvement compared to the left side.What is the likely diagnosis?

A client receives a prescription for ophthalmic ketorolac.Prior to administering the medication, the nurse should review the medical record for which condition?

A client with open-angle glaucoma asks the nurse how long the prescribed eye drops will need to be used. Which response made by the nurse is accurate?